Clin: Operative deliveries - Wootton Flashcards
what are the contraindications for operative vaginal delivery?
- if fetal head is not engaged
- position of fetal head is unknown
- fetus is suspected to have bone demineralization condition (osteogenesis imperfecta)
- bleeding disorder suspected (alloimmune thrombocytopenia, hemophilia or VWB)
- maternal exhaustion/lack of expulsive effort
- inability to have expulsive effort (spinal cord injuries, neuromuscular disorder)
- need to avoid maternal expulsive efforts (certain cardiac conditions)
- non-reassuring fetal status (bradycardia, repetitive decels)
- prolonged second stage of labor
indications for operative vaginal delivery
what is considered a prolonged 2nd stage of labor for nulliparous mom?
> 2hrs without regional anesthesia
>3 hours with regional anesthesia
what is considered prolonged 2nd stage of labor for multiparous mom?
> 1hr without regional anesthesia
>2hrs with regional anesthesia
what are the maternal criteria for operative vaginal delivery?
- adequate analgesia
- lithotomy position
- empty bladder
- consent
what are the fetal criteria for operative vaginal delivery?
- vertex position
- fetal head must be engaged (biparietal diameter at 0 station)
- position of fetal head must be known with certainty
- estimation of fetal weight performed
- station of fetal head must be > +2
what are the uteroplacental criteria for operative vaginal delivery?
- cervix fully dilated
- membranes ruptured
- no placenta previa
NOTE: must also be in a facility where emergent c-section can be performed if something goes wrong
what type of forceps used for breech presentation?
PIPER forceps
leading point of the fetal head is at +2 station or more, is not on the pelvic floor (can be rotational or non-rotational)
LOW operative vaginal delivery
fetal skull is above +2 station
midpelvis and high forceps operative vaginal delivery
- NOT EVER INDICATED TODAY
forcep blades should fit the fetal head evenly
- should lie against what?
the fetal head so that they cover the space between the orbits and ears
how is traction applied with forceps?
in the plane of least resistance
- follows the pelvic curve
IF IT DOESN’T COME EASY -> STOP
- laceration of the vagina/cervix
- episiotomy extension
- pelvic hematomas
- urethral and bladder injuries
- uterine rupture
maternal complications of forceps delivery
- minor facial lacerations
- forceps marks
- facial and brachial plexus injuries
- skull fracture
- intracranial hemorrhage
fetal complications of forceps delivery
what is the advantage to vacuum assisted vaginal delivery?
delivery can be achieved with little maternal analgesia
same indications/requirements as forceps
what are the contraindications to vacuum delivery?
- gestational age <34 wks
- suspected fetal macrosomia
- suspected fetal coagulation disorder
- breech presentation
vacuum is applied to fetal head with mechanical pump 2cm anterior to what?
- *the posterior fontanelle and centered over the sagittal suture**
- steady traction
- no rocking or torque on device
- 5% incidence serious complications
what 3 checks should be undertaken with vacuum extractor?
- no maternal tissue trapped in cup
- cup should be placed in midline of sagittal suture
- vacuum port of the suction cup should point toward to occiput
NOTE: no more than 2 “pop offs” allowed, should not be applied more than 20 mins, no torsion or twisting of device
which of the two operations have:
- more failed deliveries
- fewer perineal injuries
- increased incidence of fetal cephalohematoma
- more scalp lacerations and bruising
vacuum (compared to forceps)
sequential use of vacuum extractor and forceps has been associated with what?
increased risk of neonatal complications and should NOT be performed routinely
what is the most common operative procedure in the US?
c-section
why is the c-section rate climbing?
repeat c-sections, continuous electronic fetal monitoring, macrosomia, decreased use of vaginal delivery methods, assisted reproductive technology, fear of litigation
- non-reassuring FHR
- breech presentation/transverse
- very low birth weight (<1500g)
- active HSV infection
- immune thrombocytopenia purpura
- congenital anomalies
fetal indications for c-section
- cephalopelvic disproportion
- failure to progress
- placental abruption
- placenta previa (other placental abnormalities like vasa previa)
maternal-fetal indications for c-section
- obstructive benign and malignant tumors
- large vulvar condyloma
- abdominal cervical cerclage
- prior vaginal colporrhapy (repairing defect in vaginal wall)
- conjoined twins
maternal indications for c-section
what are the 3 abdominal incision locations named (from closest to belly button down to pubic bone)
- Maylard
- Joel-Cohen
- Pfannenstiel
what are the c-section intraoperative complications?
- uterine artery lacerations
- bladder injuries
- ureteral injuries
- GI tract injury
- uterine atony
- placenta accreta
- cesarean hysterectomy
what are the post-op complications of a c-section?
- endomyometritis
- wound complication
- urinary complications (retention, infection)
- GI complication (ileus, diarrhea)
- thromboembolic disorders (pulm emboli/DVT)
